From the Guidelines
The management of pulmonary embolism (PE) should prioritize anticoagulation with unfractionated heparin (UFH), including a weight-adjusted bolus injection, initiated without delay in patients with high-risk PE, as recommended by the 2019 ESC guidelines 1. The initial management of PE involves anticoagulation to reduce the risk of further clot formation and recurrence.
- Anticoagulation options include:
- Unfractionated heparin (UFH) with an initial bolus of 80 units/kg followed by continuous infusion at 18 units/kg/hour, adjusted to maintain aPTT at 1.5-2.5 times normal
- Low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily or fondaparinux 5-10 mg daily based on weight
- For long-term treatment, direct oral anticoagulants (DOACs) like rivaroxaban or apixaban, or warfarin (target INR 2-3) should be considered, as suggested by the 2012 American College of Chest Physicians evidence-based clinical practice guidelines 1.
- In patients with cancer, the choice between LMWH and edoxaban or rivaroxaban is left to the discretion of the physician, and the patient’s preference, as stated in the 2019 ESC guidelines 1.
- For massive PE with hemodynamic instability, thrombolytic therapy with alteplase 100 mg IV over 2 hours should be considered, as recommended by the 2019 ESC guidelines 1.
- Oxygen supplementation should be provided to maintain saturation above 90%, and hemodynamically unstable patients require ICU admission for close monitoring.
- Inferior vena cava filters are reserved for patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation, as stated in the 2019 ESC guidelines 1. Key considerations in the management of PE include:
- Prompt diagnosis and treatment to reduce mortality and morbidity
- Individualized treatment approach based on patient-specific factors, such as cancer status and bleeding risk
- Regular reassessment of the risk-to-benefit ratio of continued anticoagulant treatment, as recommended by the 2019 ESC guidelines 1.
From the FDA Drug Label
1.3 Treatment of Pulmonary Embolism XARELTO is indicated for the treatment of pulmonary embolism (PE).
- 4 Reduction in the Risk of Recurrence of Deep Vein Thrombosis and/or Pulmonary Embolism XARELTO is indicated for the reduction in the risk of recurrence of DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months.
1.4 Treatment of Pulmonary Embolism Apixaban tablets are indicated for the treatment of PE.
The management of pulmonary embolism (PE) includes treatment with rivaroxaban (XARELTO) 2 or apixaban 3. These medications are indicated for the treatment of PE. Rivaroxaban is also indicated for the reduction in the risk of recurrence of DVT and/or PE after completion of initial treatment.
From the Research
Management of Pulmonary Embolism (PE)
The management of pulmonary embolism (PE) involves various treatment options, including:
- Fibrinolytics
- Surgical embolectomy
- Catheter-directed treatment
- Vena cava filter placement
- Traditional parenteral anticoagulants, used alone or as a bridge to a vitamin K antagonist (VKA) 4
- Direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban, which allow for single drug therapy and eliminate the need for initial parenteral anticoagulation 4, 5
Anticoagulation Therapy
Anticoagulation is the mainstay of treatment for acute pulmonary embolism 6. The choice of anticoagulation management is important, especially in intermediate and high-risk patients 7. The preferred choice of anticoagulation management includes direct oral anticoagulants, while vitamin K antagonists and low-molecular-weight heparin are preferred in special populations or selected patients 7.
Special Populations
Special populations, such as patients with liver failure, renal failure, malignancy, and COVID-19, require careful consideration when selecting anticoagulants 5, 7. Additionally, patients with renal impairment, malignancy, and obesity may require special consideration when managing PE 4, 7.
Risk Stratification
Risk stratification is crucial in managing PE, as it allows for tailored clinical management according to the severity of the disease 6. Patients can be stratified into high, intermediate, and low risk of adverse outcomes, based on their haemodynamic status and right ventricular overload 6.
Duration of Therapy
The duration of anticoagulation therapy depends on the individual patient's risk factors and the presence of continuing risk factors such as cancer or clinical markers such as residual vein thrombosis and elevated d-dimers 4. Pulmonary embolism provoked from transient risk factors often requires a short-term course of anticoagulation (3 months), while unprovoked events and those that occur in the presence of continuing risk factors may warrant extended anticoagulation 4.